A provincial investigation found staff at a Calgary nursing home violated the law by failing to inform authorities when its residents were sexually abused.

The Alberta Health report also determined actions taken by management at McKenzie Towne Care Centre eight years ago were “insufficient” to halt repeated assaults by a male resident on women in the facility’s dementia unit.

“Failure to report is an offence under the Protection of Persons in Care Act and is subject to a fine or imprisonment,” the report said.

“Former management was aware of the alleged abuser’s actions, which were first evidenced in June (2005) . . . and significantly escalated over the next six months.”

Despite the finding, it appears the offences — which at the time carried a maximum fine of $2,000 or up to six months in jail — were never prosecuted.

Alberta Health officials did not respond to questions about why charges were not laid.

The son of one victim, whom the Herald has agreed not to identify, says the problems at the Revera Inc. facility might never have come to light if he hadn’t witnessed one of the assaults with his own eyes and filed the PPIC complaints.

“This is another sad example of how for-profit companies and the Alberta government care for seniors,” he said.

“Those responsible for allowing this to happen should have been charged and the government officials should have either pulled public funding or had people on site to ensure something like this never happened again.”

News of the 2006 investigation comes in the wake of provincial audits of McKenzie Towne prompted by last year’s deaths of two residents.

In both those cases, the elderly patients developed severe blood poisoning after they were left for extended periods in soiled or soaking diapers.

Health Minister Fred Horne had threatened in December to cancel Revera’s contract after the Herald first reported on the incidents.

But after last month’s audits, Horne insisted that residents were safe and there were no systemic problems at the 150-bed facility.

Shannon Stunden-Bower, research director at the Parkland Institute, said the recurring care issues at McKenzie Towne are likely linked to inadequate staffing.

Stunden-Bower co-authored a recent report that found private nursing homes in Alberta provide their residents with 30 per cent less direct care than the minimum recommended by a group of North American experts.

The report also revealed that for-profit facilities also had far fewer registered nurses than recommended to properly oversee care.

“If you don’t have enough people with the right training and supervision, then terrible things like this are going to happen,” Stunden-Bower said.

The sexual abuse investigation in 2006 found the male resident assaulted at least three women in McKenzie Towne’s dementia ward during the six months he lived in the secure unit.

Front-line staff and the facility’s director of care admitted there had been a number of incidents where the man was observed “firmly grabbing” the breasts of female patients.

“The behaviour significantly escalated through the end of 2005 and into January 2006 wherein five separate incident reports were submitted,” the report said.

Caregivers said they attempted to redirect the male resident when he behaved inappropriately.

But a nurse on the ward said staff shortages meant the facility was unable to provide enough one-to-one supervision to prevent repeat attacks, a statement the investigator dismissed as a “rationalization for insufficient intervention.”

The son of one victim decided to file a complaint after he saw the man fondling a bedridden female.

He told the PPIC investigator that staff members he confronted about the abuse said they had been told to “remain silent in informing family members” if their loved ones were assaulted.

“From the director of care right down to the front-line staff,” he said he was left with the impression that they did not seem to “appreciate the gravity of these incidents or even have policies to deal with the situation,” he said in a recent interview.

The report recommended that staff be properly trained on the PPIC legislation and how to deal with and prevent abuse.

Given the large number of caregivers for whom English is a second language, the facility said then that it would not be feasible to have them record incidents on a resident’s chart.

The investigator was also critical of delays in providing written information about facility policies to relatives of residents.

“During previous unrelated investigations at this facility, reference was made to the “Handbook” that was in the process of being produced,” the report said.

“The lack of a reference document . . . appears to contribute to family confusion and misinformation regarding a client’s care and placement.”

Officials with Revera — which operates 242 seniors facilities across North America, including 15 in Alberta — were not available to be interviewed for this story.

But the company issued a statement saying all staff, regardless of their literacy, can now use icons on point of care computer terminals to log an incident when they see it happen.

“Duty to report any alleged, potential, suspected or witnessed abuse is clear in our policies,” the statement said.

“It’s clear from the findings . . . that this situation was unacceptable and we regret any distress that this may have caused the resident(s) and family involved.”

The investigation report indicates that after the son’s complaints were filed, McKenzie Towne promptly transferred the male resident to another facility where he would not have contact with females.

It also shows that in the wake of the investigation, the nursing home finally produced a handbook for families, hired a new care director and promised the province it would mend the relationship with the son who complained through mediation.

But in the subsequent 18 months before his mother died, the son says he tried in vain to arrange a discussion with McKenzie Towne’s management.

“I was never able to sit down with anyone and hear what they were doing to prevent these sort of incidents,” he said. “It made me wonder whether they really had a plan to keep vulnerable residents like my mother safe.”

Almost Done!

Postmedia wants to improve your reading experience as well as share the best deals and promotions from our advertisers with you. The information below will be used to optimize the content and make ads across the network more relevant to you. You can always change the information you share with us by editing your profile.

By clicking "Create Account", I hearby grant permission to Postmedia to use my account information to create my account.

I also accept and agree to be bound by Postmedia's Terms and Conditions with respect to my use of the Site and I have read and understand Postmedia's Privacy Statement. I consent to the collection, use, maintenance, and disclosure of my information in accordance with the Postmedia's Privacy Policy.

Postmedia wants to improve your reading experience as well as share the best deals and promotions from our advertisers with you. The information below will be used to optimize the content and make ads across the network more relevant to you. You can always change the information you share with us by editing your profile.

By clicking "Create Account", I hearby grant permission to Postmedia to use my account information to create my account.

I also accept and agree to be bound by Postmedia's Terms and Conditions with respect to my use of the Site and I have read and understand Postmedia's Privacy Statement. I consent to the collection, use, maintenance, and disclosure of my information in accordance with the Postmedia's Privacy Policy.